Assessment of Telestroke Capacity in US Hospitals | Cerebrovascular Disease | JAMA Neurology | JAMA Network
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Figure.  Number of Hospitals in the US Incorporating Telestroke by Year, 2001-2019 (N = 1306)
Number of Hospitals in the US Incorporating Telestroke by Year, 2001-2019 (N = 1306)

Free-standing emergency departments with telestroke capacity were linked to their affiliated hospital. The 15 organizations contributing data are Blue Sky Neurology, Integris, InTouch, Mayo Clinic, Medical University of South Carolina, Northwestern Memorial Hospital, Partners HealthCare, Providence Health, SOC Telemed (formerly Specialists on Call), Stanford Health Care, University of Pittsburg Medical Center, University of Utah Hospital, Vanderbilt University Medical Center, Virginia Mason, and Wake Forest Baptist Health. These networks may provide telestroke services to hospitals across several states.

Table.  Characteristics of Hospitals With and Without Telestroke Capacity by 2019
Characteristics of Hospitals With and Without Telestroke Capacity by 2019
1.
Wechsler  LR, Tsao  JW, Levine  SR,  et al; American Academy of Neurology Telemedicine Work Group.  Teleneurology applications: report of the Telemedicine Work Group of the American Academy of Neurology.   Neurology. 2013;80(7):670-676. doi:10.1212/WNL.0b013e3182823361PubMedGoogle ScholarCrossref
2.
Silva  GS, Farrell  S, Shandra  E, Viswanathan  A, Schwamm  LH.  The status of telestroke in the United States: a survey of currently active stroke telemedicine programs.   Stroke. 2012;43(8):2078-2085. doi:10.1161/STROKEAHA.111.645861PubMedGoogle ScholarCrossref
3.
Zachrison  KS, Boggs  KM, M Hayden  E, Espinola  JA, Camargo  CA.  A national survey of telemedicine use by US emergency departments.   J Telemed Telecare. Published online December 17, 2018. doi:10.1177/1357633X18816112Google Scholar
4.
Zhang  D, Wang  G, Zhu  W,  et al.  Expansion of telestroke services improves quality of care provided in super rural areas.   Health Aff (Millwood). 2018;37(12):2005-2013. doi:10.1377/hlthaff.2018.05089PubMedGoogle ScholarCrossref
5.
Müller-Barna  P, Schwamm  LH, Haberl  RL.  Telestroke increases use of acute stroke therapy.   Curr Opin Neurol. 2012;25(1):5-10. doi:10.1097/WCO.0b013e32834d5fe4PubMedGoogle ScholarCrossref
6.
Lichtman  JH, Leifheit-Limson  EC, Jones  SB, Wang  Y, Goldstein  LB.  30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals.   Stroke. 2012;43(10):2741-2747. doi:10.1161/STROKEAHA.112.665646PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    TELESTROKE FACILITIES AROUND THE WORLD
    Khichar Shubhakaran, MD (Med), D.M.(Neurology) | Senior Professor and Head of the Department of Neurology, MDM Hospital, Dr. S.N. Medical College, Jodhpur, India-342003.
    Telestroke facilities are the likely emerging future of stroke patients. This survey of such facilities in the US is a welcome step and should be encouraged all around the world (1). The authors report excellent results in terms of greater use of reperfusion and better outcomes, and the facilities were available in around one quarter of centres surveyed in US. The services were less common in rural and remote areas because of less robust capital investment, internet or telecom services, and because of regulatory barriers.
    Mobile stoke unit/ ambulances equipped with neuroimaging and interventions are likely more yielding as shown
    in various studies and observations (2,3). As Covid-19 is teaching the world about telehealth, there should be provisions for such services all around the world to reduce the morbidity and mortality from stroke. The greatest barrier will be financial constraints and availability of trained staff, which may be overcome by a comprehensive programme at regional or broader worldwide levels as per the feasibility of time, limitations and other hurdles.

    References

    1. Jessica R V, Wilcock A D, Schwamm L H et al. Assessment of Telestroke Capacity in US Hospitals.
    JAMA Neurol. 2020;77(8):1035-1037. doi:10.1001/jamaneurol.2020.1274.

    2. Kummer R B, Lerario M P, Hunter M D et al. Geographic Analysis of Mobile Stroke Unit Treatment in a Dense Urban Area: The New York City METRONOME Registry. https://doi.org/10.1161/JAHA.119.013529Journal of the American Heart Association. 2019;8

    3. Treating stroke patients in specialised ambulances speeds treatment and reduces patients’ disability, according to late-breaking science presented at the International Stroke Conference (ISC; 19–21 February, Los Angeles, USA).
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    May 26, 2020

    Assessment of Telestroke Capacity in US Hospitals

    Author Affiliations
    • 1Harvard Medical School, Boston, Massachusetts
    • 2University of Vermont Medical School, Burlington
    • 3Massachusetts General Hospital, Boston
    • 4RAND Corporation, Arlington, Virginia
    • 5Texas Tech Health Science Center, Lubbock
    • 6Beth Israel Deaconess Medical Center, Boston, Massachusetts
    JAMA Neurol. 2020;77(8):1035-1037. doi:10.1001/jamaneurol.2020.1274

    Reperfusion via intravenous alteplase or mechanical thrombectomy reduces the damage of an acute ischemic stroke, but these treatments must be administered within a narrow time frame after onset of symptoms and not all patients can safely receive reperfusion. Larger hospitals typically have on-call stroke teams that quickly assess patients with suspected stroke; patients receiving care at hospitals without this expertise may be less likely to receive appropriate treatment.1 Telestroke has emerged as a potential solution by which remote stroke experts guide local emergency physicians through the neurological examination, review of imaging, and management decisions.1

    Limited evidence exists on the prevalence of telestroke capacity in hospitals.2,3 There is no comprehensive survey of when hospitals introduced their telestroke programs, and the use of telestroke cannot be reliably identified in insurance claims.4 We describe the growth of telestroke capacity in US hospitals and compare the characteristics of the hospitals with and without telestroke capacity.

    Methods

    In consultation with stroke experts about existing telestroke programs in the US and review of the literature, we identified and contacted 15 health care systems and private companies with known telestroke capacity (Figure). All agreed to participate and provided the names and contract start dates of hospitals in their networks on the requesting end of telestroke consults (spoke hospitals). This is a convenience sample and does not capture all telestroke sites and most likely underrepresents smaller networks. Harvard Medical School waived insitutional review board approval for this study because the study did not involve human subjects data.

    Our sample included all short-term acute care hospitals and critical access hospitals open in 2017 (using most recent data available) with at least 1 stroke hospitalization in Medicare fee-for-service data. We linked our list of hospitals with telestroke capacity to this list using hospital name and city.

    We described telestroke uptake from January 2001 to December 2019 and then compared characteristics of hospitals with telestroke capacity by 2019 vs those without via χ2 tests. Hospital characteristics came from 2017 Medicare data for hospital rural/urban status, census region, and bed count, 2016 Centers for Disease Control and Prevention data for neurologists per capita ratio by hospital county, and 2017 American Hospital Association survey data for all other characteristics (Table). P values were 2-sided, and the signifiance threshold was .05.

    Results

    By 2019, 1306 of 4751 hospitals (27.4%) had telestroke capacity. Uptake grew slowly and peaked in 2014 (Figure). Of hospitals open in 2017, hospitals with telestroke capacity were larger (523 [33.5%] in the highest quartile with telestroke capacity vs 201 [14.8%] in the lowest; P < .001; χ2 = 212.1), more likely to be short-term acute care hospitals (1077 [31.7%] vs 229 [17.0%] of critical-access hospitals; P < .001; χ2 = 105.2), and in urban areas (856 [30.2%] vs 450 [23.5%] rural; P < .001; χ2 = 25.8). They were also more likely to be in the West, in counties with fewer neurologists per capita, have for-profit ownership, and have intensive care units (Table).

    Discussion

    In one of the first national compilations of telestroke capacity to our knowledge, we found that approximately a quarter of hospitals now have access to this technology for patients in their emergency departments. Given that telestroke capacity is associated with greater use of reperfusion,5 the growing use of telestroke in the US hopefully leads to more reperfusion and improved outcomes.

    Smaller, rural, and critical access hospitals, the group of hospitals that might benefit most from telestroke,6 are relatively less likely to have adopted this technology. It is unclear what barriers these hospitals face in introducing telestroke capacity. Potential barriers include lack of capital investment, lack of high-speed internet in rural communities, and regulatory barriers (eg, Stark Laws limit the material support that can be provided to referring hospitals).

    The key limitation to this research is that our sample of telestroke networks was identified primarily through consultations with experts and as such may overrepresent larger systems of care anchored by teaching hospitals or using private telestroke companies.

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    Article Information

    Corresponding Author: Ateev Mehrotra, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (mehrotra@hcp.med.harvard.edu).

    Published Online: May 26, 2020. doi:10.1001/jamaneurol.2020.1274

    Author Contributions: Dr Mehrotra had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Richard, Uscher-Pines, Zachrison, Siddiqui, Mehrotra.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Richard.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Richard, Zachrison, Mehrotra.

    Obtained funding: Uscher-Pines, Mehrotra.

    Administrative, technical, or material support: Richard, Wilcock.

    Supervision: Schwamm, Uscher-Pines, Mehrotra.

    Conflict of Interest Disclosures: Dr Schwamm reports serving as a scientific consultant to Genentech regarding trial design and conduct on late window thrombolysis, to Life Image regarding user interface design and usability, and to the Massachusetts Department of Public Health on stroke systems of care; reports grant funding from Comparative Effectiveness of Early Integrated Telehealth Versus In-Person Palliative Care for Patients with Advanced Lung Cancer REACH-PC and Patient-Centered Outcomes Research Institute; and serves as a member of the international advisory board for The Lancet-Digital Health (2019-present). Dr Zachrison reports grant funding from the Agency for Healthcare Research and Quality and the American Heart Association. No other disclosures were reported.

    Funding/Support: This research was supported by the National Institute of Neurological Disorders and Stroke (grant R01NS111952).

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Wechsler  LR, Tsao  JW, Levine  SR,  et al; American Academy of Neurology Telemedicine Work Group.  Teleneurology applications: report of the Telemedicine Work Group of the American Academy of Neurology.   Neurology. 2013;80(7):670-676. doi:10.1212/WNL.0b013e3182823361PubMedGoogle ScholarCrossref
    2.
    Silva  GS, Farrell  S, Shandra  E, Viswanathan  A, Schwamm  LH.  The status of telestroke in the United States: a survey of currently active stroke telemedicine programs.   Stroke. 2012;43(8):2078-2085. doi:10.1161/STROKEAHA.111.645861PubMedGoogle ScholarCrossref
    3.
    Zachrison  KS, Boggs  KM, M Hayden  E, Espinola  JA, Camargo  CA.  A national survey of telemedicine use by US emergency departments.   J Telemed Telecare. Published online December 17, 2018. doi:10.1177/1357633X18816112Google Scholar
    4.
    Zhang  D, Wang  G, Zhu  W,  et al.  Expansion of telestroke services improves quality of care provided in super rural areas.   Health Aff (Millwood). 2018;37(12):2005-2013. doi:10.1377/hlthaff.2018.05089PubMedGoogle ScholarCrossref
    5.
    Müller-Barna  P, Schwamm  LH, Haberl  RL.  Telestroke increases use of acute stroke therapy.   Curr Opin Neurol. 2012;25(1):5-10. doi:10.1097/WCO.0b013e32834d5fe4PubMedGoogle ScholarCrossref
    6.
    Lichtman  JH, Leifheit-Limson  EC, Jones  SB, Wang  Y, Goldstein  LB.  30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals.   Stroke. 2012;43(10):2741-2747. doi:10.1161/STROKEAHA.112.665646PubMedGoogle ScholarCrossref
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